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Page 2 of 10 Walter et al. Vessel Plus 2021;5:27 https://dx.doi.org/10.20517/2574-1209.2020.102

implementation of an Air-MSU are discussed. Innovative health care solutions are urgently needed to close the
treatment gap for stroke patients living in rural and remote regions worldwide.

Keywords: Air-MSU, remote areas, stroke treatment, pre-hospital stroke management, stroke thrombolysis,
thrombectomy

INTRODUCTION
Stroke and global effects
Stroke is the second most common cause of death and accounts for 12% of all deaths worldwide. Projections
by World Health Organisation for 2016 to 2060 do not predict any improvement. While some areas of the
world, such as America and Europe, might see a drop in their numbers, others, like Africa and Western
Pacific regions are expected to face an increase in stroke deaths .
[1]
Currently, there are approximately 80 million stroke survivors globally, and due to population growth and
aging, this number is predicted to increase dramatically. Stroke is the leading contributor (42.2%) to
disability-adjusted life-years, which is the sum of years of life lost and years lived with disability. This
[2]
number is also predicted to increase .
Despite significant advances in new therapies to treat stroke, one of the most important challenges in stroke
management today is the delivery of these therapies to rural and remote areas. Access to the most effective
therapies, thrombolysis or thrombectomy, for patients with acute ischaemic stroke has become a “postcode
lottery.” In other words, the geographical location of residence defines the available access to acute stroke,
leading to an unacceptable inequity of opportunity. This applies not only to developing nations, but also to
some of the wealthiest countries. Even in well-resourced regions, there are surprising problems in health
care delivery and equitably to all people regardless of location. It is important to recognize that 44 % of the
world’s population lives in rural and remote areas with only limited access to high-quality stroke care . This
[3]
[4,5]
is often most markedly affecting those of indigenous background .
Where you live defines what you get
Delivery of the three major evidence-based acute ischaemic stroke treatments, which strongly influence
mortality and disability - treatment on a stroke unit, thrombolysis in ischaemic stroke, and endovascular
thrombectomy for those with large vessel occlusion - is challenging in areas with a low population density.
It is known that the distance to the nearest stroke centre is a crucial factor for delivery of timely stroke
[8,9]
[6,7]
treatment . Reported times from symptom onset to admission to rural hospitals range from 5-30 h .
These pre-hospital delays have subsequently been attributed as a major driver of the very low thrombolysis
rates of only 1%-6% for patients in rural areas worldwide [10-12] . This contrasts with rates of 20%-25% in
metropolitan stroke centres. The decisions about the type of care and how access to acute care will be
achieved is most often dominated by the question of cost efficiency rather than need. The reality is that
patient numbers in these rural and remote areas are often too low to enable an economically viable service.
This, together with the view that the individual preference and decision to live in rural/remote areas should
not increase health care costs of the whole society, impedes process improvement.

The quality of acute stroke management varies between countries, but interestingly, also within regions of
individual countries. This not only applies to middle- or low-income countries, which lack the financial
resources to establish high-quality care for what is, in reality, only a few people, but also to high income
countries.